1 addressing behaviors that undermine a culture of safety: it starts with a cup of coffee gerald b....

1 Addressing Behaviors that Undermine a Culture of Safety: It Starts with a Cup of Coffee Gerald B. Hickson, MD Sr. Vice President for Quality, Safety and Risk Prevention Assistant Vice Chancellor for Health Affairs Joseph C. Ross Chair in Medical Education & Administration

2 Pursuing Reliability Definition: Failure free operation over time effective, efficient, timely, pt-centered, equitable Requires: Vision/goals/core values Leadership/authority (modeled) A safety culture = willingness to report and address Psychological safety Trust Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001; Nolan et al. Improving the Reliability of Health Care. IHI Innovation Series. Boston: Institute for Healthcare Improvement; 2004; Hickson et al. Chapter 1: Balancing systems and individual accountability in a safety culture. In: Berman S., ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

3 Professionals commit to: Technical and cognitive competence Professionals also commit to: Clear and effective communication Being available Modeling respect Self-awareness Professionalism promotes teamwork Professionalism demands self- and group regulation Professionalism and Self-Regulation Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

4 Sometimes you just suspect a disturbance in the force

5 What data exists Post-op infection rates above the national average

6 Response: We need a plan A multidisciplinary team was charged to assess and evaluate: Current performance Opportunities for improvement Plan development

Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources; 2012:1-36.SIU

8 The Plan: Colorectal Bundle Standardization of care for the colon surgery patient: Communication of expectations Evidence-based optimal bundle 9 elements: bowel prep wound protector change gown and gloves etc. Education across service lines Ongoing monitoring and compliance measurement Monthly review and analysis of surgical site infection Problem Solved

9 So everyone responded in a professional way? Well not exactly

10 The following event was reported to you (responsible party) through an event reporting system. Policy defines that you review and follow up. A nurse reports: Dr. X was performing a transverse colon resection. At the appropriate point in surgery, Nurse Y stated, Dr. X, you need to re-gown and glove per our colorectal bundle. The following event was reported to you (responsible party) through an event reporting system. Policy defines that you review and follow up. A nurse reports: Dr. X was performing a transverse colon resection. At the appropriate point in surgery, Nurse Y stated, Dr. X, you need to re-gown and glove per our colorectal bundle. Case: Re-Gown and Glove

11 Dr. X replied, I dont agree with that element of the bundle and Im not stopping now to change gowns and gloves. Dr. X continued with procedure Case: Re-Gown and Glove Threat to safety?

12 Why Might a Medical Professional Behave in Ways that Undermine a Culture of Safety? 1. Substance abuse, mental health issues 2. Narcissism, perfectionism 3. Spillover of family/home problems 4. Poorly controlled anger (2 emotion)/Snaps under heightened stress, perhaps due to: a. Poor clinical/administrative/systems support b. Poor mgmt skills, dept out of control c. Back biters create poor practice environments Samenow CP. Swiggart W. Spickard A Jr. A CME course aimed at addressing disruptive physician behavior. Physician Executive. 34(1):32-40, 2008.

13 Why Might a Medical Professional Behave in Ways that Undermine a Culture of Safety? 5. Lack of awareness of impacts on others 6. Make others look bad - for some advantage 7. Distract from own shortcomings 8. Family of origin issuesguilt and shame 9. Well, it seems to work pretty well (Why? See #10) 10. No one addressed it earlier (Why?) Samenow CP. Swiggart W. Spickard A Jr. A CME course aimed at addressing disruptive physician behavior. Physician Executive. 34(1):32-40, 2008.

Lawsuits Non adherence/ noncompliance Surgical Complication Consequences of Unsafe Behavior: Patient Perspective Drop out (tip of the iceberg) Infections/ Errors Bad-mouthing the hospital/ practice to others Costs Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

Harassment suits Jousting Consequences of Unsafe Behavior: Healthcare Professional Perspective Burnout (tip of the iceberg) Lack of retention Infections/ Errors Bad-mouthing the organization in the community 15 Costs Felps W, et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups., Research and Organizational Behavior. 2006; 27:175-222.

FY09 FY10 FY11 FY12 FY13 CLABSI ICU 169 172 65 40 33 FY09 SIR: 3.16 FY13 SIR: 0.62 80% SIR and event reduction CLABSI NonICU 188* 96 65 68 FY10 SIR: 3.09 FY13 SIR: 0.93 70% SIR and 64% event reduction *Extrapolated from 6 months of data CAUTI ICU 114 111 88 84 76 FY09 SIR: 1.36 FY13 SIR: 1.01 28% SIR and 33% event reduction CAUTI NonICU 51 24 FY12 SIR: 1.29 FY13 SIR: 0.56 57% SIR and 53% event reduction SSI 286* 266 263 183 161 FY09 SIR: 1.64 FY13 SIR: 0.98 40% SIR and 44% event reduction *Extrapolated from 6 months of data Procs = CARD, CSEC, COLO, HYST, CABG, CBGC, CRAN, HIP, KNEE, Peds CARD, Peds VSHUNT. REC, VHYST VAP** 145 151 76 56 FY09 SIR: 2.86 FY12 SIR: 1.12 61% SIR and event reduction Numbers Noted are the Number of Specific HAI Events All SIR benchmarked to FY14 benchmarks **VUH and MCJCHV

17 Infect- ion FY10 Pre HH Interv. (baseline) FY11-13 Expected # Infectns FY11-13 Actual # Infectns # Fewer Infectns Over 3 Yrs Mean Attrib Cost/ Infection* Est. 3-Yr Savings Clabsi172516138378$22K $8.3MM VAP*151302132170$24.5K $4.2MM SSI298894669225$19K $4.3MM CAUTI- ICU 11133324885$1.5K $0.1MM Estimated Savings 858 infections $16.9MM Estimated Infection Control Impacts Following Interventions to Promote Accountability *VAP Surveillance ended mid-FY13 Estimates based on data in: Perencevich, et al. SHEA Guideline. Raising standards while watching the bottom line: Making a business case for infection control. Infect Control Hosp Epidemiol. 2007;8:1121-1133.

18 Failure to Address Behaviors that Undermine a Culture of Safety Leads To: Felps W et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior. 2006;27:175-222. Adoption of unprofessional conduct Lessened trust, lessened task performance (always monitoring disruptive person) Threatened quality and patient safety Withdrawal

19 The Balance Beam Do nothingDo something Staff satisfaction and retention Reputation Patient safety, clinical outcomes Liability, risk mgmt costs Fear of antagonizing Leaders blink Not sure how lack tools, training Competing priorities Cant change Studer Group and Vanderbilt Center for Patient and Professional Advocacy, Unprofessional Behavior in Healthcare Study, June 2009; Hickson GB, Pichert JW. Disclosure and apology. In: National Patient Safety Foundation Stand Up for Patient Safety Resource Guide, 2008; Pichert JW, Hickson GB, Vincent C: Communicating about unexpected outcomes and errors. In: Carayon P, ed. Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, 2007.

20 Professionals commit to: Technical and cognitive competence Professionals also commit to: Clear and effective communication Being available Modeling respect Self-awareness Professionalism promotes teamwork Professionalism demands self- and group regulation Professionalism and Self-Regulation Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

21 To do something requires more than a commitment to professionalism and personal courage. It requires a plan (people, process and technology).

22 1.Leadership commitment (will not blink) 2.Goals, a credo, and supportive policies 3.Surveillance tools to capture observations/data 4.Processes for reviewing observations/data 5.Model to guide graduated interventions 6.Multi-level professional/leader training 7.Resources to address unnecessary variation 8.Resources to help affected staff and patients Infrastructure for Promoting Reliability & Professional Accountability (PA) Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring and addressing unprofessional behaviors. Acad Med. 2007 Nov;82(11):1040-1048. Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Chapter 1: Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36.

23 What are behaviors that undermine a culture of safety? Accountability

24 Definition of Behaviors That Undermine a Culture of Safety Excepts from Vanderbilt University and Medical Center Policy #HR-027, 2010 Create intimidating, hostile, offensive (unsafe) work environment Interfere with ability to achieve intended outcomes Threaten safety (aggressive or violent physical actions) Violate policies (including conflicts of interest and compliance) Its About Safety

25 Policies will not work if behaviors that undermine a culture of safety go unobserved, unreported and unaddressed

26 Hand Hygiene Performance What Are Surveillance Tools? Hickson GB, Moore IN, Pichert JW, Benegas Jr M. Chapter 1: Balancing systems and individual accountability in a safety culture. In: Berman S, ed. From Front Office to Front Line. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2012:1-36. Staff Concerns Risk Event Reporting System Patient Relations Department

27 Reports of Unprofessional Behavior RN: Dr. __ entered the room without foaming inproceeded to touch area with purulent drainageI offered a pair of gloveshe took them and dropped them into the trash can RN: Nurse on shift before me didnt assess need for catheter and I found a kink in the bag Anesth: Dr. __ rushedsaid to team setting up barrier wound protection [per bundle], Just use standard wound precautions. Lets get going.

28 Academic vs. Community Medical Center Physicians

29 Co-Worker Observation Reporting System: VUMC Physicians 3 years

30 Level 2 Guided" Intervention by Authority Apparent pattern Single unprofessional" incidents (merit?) "Informal" Cup of Coffee Intervention Level 1 "Awareness" Intervention Level 3 "Disciplinary" Intervention Pattern persists No Vast majority of professionals - no issues - provide feedback on progress Mandated Reviews Egregious* Mandated Ray, Schaffner, Federspiel, 1985. Hickson, Pichert, Webb, Gabbe, 2007. Pichert et al, 2008. Mukherjee et al, 2010. Stimson et al, 2010. Pichert et al, 2011. Hickson & Pichert, 2012. Hickson et al, 2012. Pichert et al, 2013. Talbot et al, 2013. Promoting Professionalism Pyramid *includes CMS-defined condition level and immediate jeopardy safety-related complaints

31 Improves physicians prescribing, clinical decision making 1 Reducing malpractice claims and expenses: By greater than 70% 2 Improving hand hygiene practices: From 50% to greater than 95% compliance 3 Addressing behaviors that undermine a culture of safety 4 Does any of this really work? 1 Schaffner W, et al. JAMA 1983;250:1728-1732; Ray WA, et al. Am J Public Health 1987;77:1448-1450; Greco PJ, Eisenberg JM. New Engl J Med 1993;329:1271-1273 2 Hickson et al. JAMA. 2002;287(22):2951-57; Hickson et al. South Med J. 2007;100(8):791-6; Pichert et al. In: Henriksen et al, editors. AHRQ; 2008: 421-30; Hickson & Pichert. In: Youngberg, editor. Jones and Bartlett Publishers; 2012: 347-68; Pichert et al. Jt Comm J Qual Patient Saf. 2013;39(10):435-46. 3 Talbot et al. Infect Control Hosp Epidemiol. 2013; 34: 1129-36 4 Dmochowski et al. Manuscript in preparation, 2014

32 Med Mal Research Background Summary 1-6%+ hosp. pts injured due to negligence ~2% of all pts injured by negligence sue ~2-7 x more pts sue w/o valid claims Non-$$ factors motivate pts to sue Some physicians attract more suits High risk today = high risk tomorrow Sloan et al. JAMA 1989;262:3291-97; Brennan et al. NEJM 1991;324: 371-376; Hickson et al. JAMA 1992;267:1359-63; Bovbjerg & Petronis. JAMA 1994;272:1421-26; Hickson et al. JAMA 1994;272:1583-87.

33 Patient Complaints While asking Dr. __ about my diagnosis, he responded that my questions were annoyingwouldnt listen and kept speaking over me We were so rushed that Dr. __ couldn't even explain why they were recommending this treatment plan for my mom over other types of treatmentsunacceptable Dr. __ left me, walked down hall, said to nurse, This pt has completely fouled up my day give her some info, and get her out of here. I heard everything Dr. __ said.

34 Academic vs. Community Medical Center Physicians

35 Gender Physician specialty Volume of service Unsolicited patient complaints Predictors of Risk Outcomes Predictive concordance of risk models ranges from 81-92% Hickson et al. JAMA. 2002 Jun 12;287(22):2951-7. (logistic regression)

36 Incurred Expense By Risk Category Predicted Risk Category* # (%) Physicians Relative Expense* % of Total Expense Score (range) 1 (low)318 (49) 1 4% 0 2147 (23) 613% 1 - 20 3 76 (12) 4 4%21 - 40 4 52 (8)4229%41 - 50 5 (high) 51 (8)7350%>50 Total644 (100) 100% * In multiples of lowest risk group Moore, Pichert, Hickson, Federspiel, Blackford. Vanderbilt Law Review. 2006.

37 Share comparative feedback with tiered interventions using the Pyramid for Promoting Reliability and Professional Accountability. Identify and train Peer Messengers Position for protection from discovery Promote accountability References Ray, Schaffner, & Federspiel, 1985. Hickson, Pichert, Webb, & Gabbe, 2007. Pichert et al, 2008. Mukherjee et al, 2010. Stimson et al, 2010. Pichert et al, 2011. Hickson et al, 2012. Pichert et al, 2013. Talbot et al, 2013. Adapted from Hickson, Pichert, Webb, & Gabbe. Acad Med. 2007. 2013 Vanderbilt Center for Patient and Professional Advocacy The PARS Process

38 Risk Score Graph Complaint Type Summary Awareness Intervention on Dr. __ Letter with standings, assurances prior to & at meeting National PARS Risk Score Comparisons

39 Unimproved/worse Successfully completed intervention process or are improving Departed organization unimproved Since FY 2000, PARS has identified >1070 U.S. physicians as high risk 64 Physicians 110 Physicians 672 Physicians Total # of high-risk physicians to date1071 Departed before 12 month follow up(79) First follow-up will be in 2014 or 2015(149) 846 with follow-up data 80% 7% 13% Pichert JW et al. An intervention model that promotes accountability: Peer messengers and patient/family complaints. Jt Comm J Qual Patient Saf. 2013 Oct;39(10):435-446. Confidential and privileged information under the provisions set forth in T.C.A. 63-1-150 and 68-11-272; not be disclosed to unauthorized persons.

Medical Malpractice Suits Per 100 Physicians SVMIC VUMC Tort Reform in TN 2008 Cert. of Merit w/ Notice2011 $750K Cap

41 Respect, trust and team performance Our latest work: Patient Complaints & Surgical Outcomes

42 Patient Complaints Dr. __ did a very poor job of communicating. He raced through an explanation of what we should expect, then left without giving us a chance to get clarification. Respectful I said I had questions. Dr.__ looked up and asked, Are you illiterate? I said No. Dr.__ responded, Oh, I just gave you a pamphlet that explains it. Since you didnt get it, I thought maybe you could not read. Clear and Effective Communication

43 NSQIP and Pt Complaints Question: Do Periop Risk Factors moderate the relationship between Patient Complaints and Surgical Outcomes? Preop Risk Factors PARS Categories Surgical Occurrences ASA ClassCare & TreatmentIntraoperative Priority StatusCommunicationWound Wound ClassConcern for Pt/FamilyUrinary AccessibilityCNS Billing w/C&T concernRespiratory Other RisksPatient ComplaintsOutcomes

44 66 surgeons; 10,536 procedures Correlations between pt complaints and occurrences: Results: Significant relationships between Occurrences & Complaints Occurrences Correlation with Patient Complaints Intraoperative0.58, p

1 addressing behaviors that undermine a culture of safety: it starts with a cup of coffee gerald b....

Documents